Poole AF/ A Flutter Clinic 2011 Diane Bruce Consultant Cardiologist PHNHSFT

Background DLB –appointed 1994 jobbing cardiologist DLB –appointed 1994 jobbing cardiologist GP lecture Lets be active about AF GP lecture Lets be active about AF 2010 Job planning changes-etc 2010 Job planning changes-etc NICE guidance re AF clinic NICE guidance re AF clinic Main problem-setting up new service Main problem-setting up new service In current cash strapped times In current cash strapped times

AF in 1995

AF in 2011

So- what happened next ? Discussion with trust managers Discussion with trust managers AF/Fl patients seen in many different settings –NOT new activity AF/Fl patients seen in many different settings –NOT new activity Aiming for consultant led rather than nurse led- WHY ? Aiming for consultant led rather than nurse led- WHY ? - ability to prescribe Class Ic drugs - ability to prescribe Class Ic drugs - refer straight on for DCV/AVN/PVI - refer straight on for DCV/AVN/PVI -deal with precipitating cardiac issues, if required. -deal with precipitating cardiac issues, if required.

Hurdles to overcome DLB availability/physiologists DLB availability/physiologists ROOM availability ROOM availability ECG/24h Tape/ECHO ECG/24h Tape/ECHO Development of clinic proforma with IT (and multiple tweakings) Development of clinic proforma with IT (and multiple tweakings) /Fax (to avoid need for typing) /Fax (to avoid need for typing) letting go phenomenon letting go phenomenon

Referral criteria Newly diagnosed AF or Atrial Flutter Newly diagnosed AF or Atrial Flutter OR AF/Flutter that is difficult to manage. OR AF/Flutter that is difficult to manage. AF and concern re other procedure AF and concern re other procedure Eg surgery etc Eg surgery etc

Going Live! 1 st week in January st week in January /12 Pilot Project 3/12 Pilot Project ONLY in house referrals-via elective OP referrals/in patient via MAU etc ONLY in house referrals-via elective OP referrals/in patient via MAU etc 4 slots per week 4 slots per week April end of pilot April end of pilot Increased to 6 slots per week Increased to 6 slots per week

Clinic Format 6 patients 30 minute consultation 6 patients 30 minute consultation All patients have 12 lead ECG/24 H ECG/TTE –unless had in last 3/12 All patients have 12 lead ECG/24 H ECG/TTE –unless had in last 3/12 Patients encouraged to bring someone along with them Patients encouraged to bring someone along with them Nuances of clinic explained Nuances of clinic explained Work through proforma Work through proforma Check all understood Check all understood AFA booklets/advice sheets AFA booklets/advice sheets

Anticoagulation CHADS2 and CHADSvasc CHADS2 and CHADSvasc Hasbled (if required) Hasbled (if required) Direct referral to anticoagulation Clinic on same day Direct referral to anticoagulation Clinic on same day AFA advice sheets AFA advice sheets

DC Cardioversion Patients requiring DCV Patients requiring DCV Consented by DLB Consented by DLB Pre-clerking and date for DCV given Pre-clerking and date for DCV given meet and greet staff on MIU meet and greet staff on MIU DCV waiting list DCV waiting list

EP referrals Made same day Made same day Urgent referrals via phone/fax/ Urgent referrals via phone/fax/ Patients given info on AVN/PVI/Flutter Ablation Patients given info on AVN/PVI/Flutter Ablation

Device Referral 5 patients had VVIR PPM 5 patients had VVIR PPM 2 patients had CRT-P 2 patients had CRT-P Others pending after DCV, ablation etc Others pending after DCV, ablation etc

Admissions Very rare-from clinic Very rare-from clinic 3 admissions with Aflutter with 2:1 Block for TOE guided DCV If atrial clot- managed appropriately

Miscellaneous Quality of Life questionnaire Quality of Life questionnaire AFEQT atrial fibrillation effect in quality of life AFEQT atrial fibrillation effect in quality of life Using proforma outside of AF clinic Using proforma outside of AF clinic

Demographics AGE RANGE less than 65y= 52 AGE RANGE less than 65y= 52 (21 F, 31 M) (21 F, 31 M) AGE RANGE (15 F, 30 M) AGE RANGE (15 F, 30 M) AGE RANGE 0ver 75 (22 F, 24 M) AGE RANGE 0ver 75 (22 F, 24 M)

Demographics CHADSvasc SCORE 0 =19 CHADSvasc SCORE 0 =19 1 =35 1 =35 2 =28 2 =28 3 =34 3 =34 4 =12 4 =12 5 = 6 5 = 6 6 =4 6 =4

Referrals DCV 30 DCV 30 VVIR PPM 5 VVIR PPM 5 EP (all) 7 EP (all) 7 Urgent angiogram 2 Urgent angiogram 2

Anticoagulation at presentation On ASPIRIN 39% On ASPIRIN 39% On WARFARIN 24% On WARFARIN 24% On nothing 46% On nothing 46%

ups and downs Increased waiting time due to number of referrals Increased waiting time due to number of referrals ?solution- more clinics ?solution- more clinics AF follow up clinics now running twice monthly AF follow up clinics now running twice monthly Interest from Stroke practitioners Interest from Stroke practitioners - stroke/cardiology MDT - stroke/cardiology MDT

ups and downs glitches eg:-hold ups with booking glitches eg:-hold ups with booking appointments appointments ECG problems ECG problems Avoiding duplication of tests etc Avoiding duplication of tests etc Increased wait for DCV as numbers increase (nurse led at Poole). Increased wait for DCV as numbers increase (nurse led at Poole).

Feedback From patients--- mostly good From patients--- mostly good word of mouth referral word of mouth referral Via Google? Via Google? Seeing patients now cured Seeing patients now cured New issue-demand for dabigatran etc New issue-demand for dabigatran etc One complaint – One complaint – Speedier anticoagulation- re close link with clinic. Speedier anticoagulation- re close link with clinic.

Feedback From GP From GP Mainly good-constructive Mainly good-constructive 1 negative (re CHADS score etc) 1 negative (re CHADS score etc) BUT useful !! BUT useful !! Increased referrals Increased referrals

Other diagnoses Uncontrolled Thyrotoxicosis Uncontrolled Thyrotoxicosis 2 ASD 2 ASD 3 severe heart failure 3 severe heart failure 2 mitral valve repairs 2 mitral valve repairs Anaemia-not uncommon Anaemia-not uncommon

Future Plans Expansion of the clinic-more follow up clinics Expansion of the clinic-more follow up clinics Improve AF diagnosis with new monitors Improve AF diagnosis with new monitors clinic letters clinic letters Improving DCV waiting times Improving DCV waiting times AUDIT AUDIT Etc,etc! Etc,etc!

Thank You Poole AF/Flutter clinic is TEAMWORK Poole AF/Flutter clinic is TEAMWORK Booking clerks/nurses/reception staff/physiologists/as well as me! Booking clerks/nurses/reception staff/physiologists/as well as me! IT for proforma and all adjustments IT for proforma and all adjustments Patients (putting up with my slow typing!) Patients (putting up with my slow typing!) AFA booklets and support AFA booklets and support